Provider Demographics
NPI:1285410746
Name:PROVENANCE HOMES
Entity type:Organization
Organization Name:PROVENANCE HOMES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SABRINA
Authorized Official - Middle Name:LUKALU
Authorized Official - Last Name:GLOBUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-741-7311
Mailing Address - Street 1:1650 W END BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5369
Mailing Address - Country:US
Mailing Address - Phone:612-261-6988
Mailing Address - Fax:612-465-1402
Practice Address - Street 1:1650 W END BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-5369
Practice Address - Country:US
Practice Address - Phone:612-261-6988
Practice Address - Fax:612-465-1402
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVENANCE HEALTHCARE STAFFING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health